Authorization for Release of Medical Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
I would like to request: (select all that apply)
*
RELEASE OF RECORDS
REQUEST OF RECORDS
RELEASE OF RECORDS
All patients have free access to their patient portal online.
Authorization
I authorize Coastal Skin Surgery and Dermatology to release my information.
Name of Person/Provider/Facility and Phone Number
Method of Disclosure *paper records: $1.00 per page up to 25 pages and $0.25 per page for all pages thereafter. *emailed records: emailing may not be a secure method of communication.
*
Mail
Fax
Pick up at Clinic
Email
Specify Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Specify Fax Number
Please enter a valid phone number.
Specify Office Location
Specify Email
example@example.com
Information to be disclosed.
*
Complete Record
Lab Reports
Pathology Reports
Medication Record
History & Physical
Surgical Records
Other
Specify Other
REQUEST OF RECORDS
Authorization
I authorize Coastal Skin Surgery and Dermatology to obtain information from the following:
Name of Person/Provider/Facility and Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number or Fax Number
Please enter a valid phone number.
Information to be obtained:
Complete Record
Lab Reports
Pathology Reports
Medication Record
History & Physical
Surgical Record
Other
Please specify:
AUTHORIZATION
Purpose of disclosure (select one)
Continuity of care
Personal use
Other
Please Specify
Picture of Driver's License or Gov't Issue ID
*
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of
This authorization will expire (insert date below)
*
I understand that if I fail to specify an expiration date, this authorization will expire twelve months from the date on which it is signed.
Specific Expiration Date
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Month
-
Day
Year
Desired Expiration Date (if left blank authorization will expire 12 months from the date on which authorization was given)
Redisclose
*
I understand that once the above information is disclosed, it may be redisclosed by the recipient and the information may not be protected by federal law or regulations.
Patient Signature - by signing this form, I authorize you to release confidential health information about me and by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/facility/entity listed below:
*
Date
*
-
Month
-
Day
Year
Today's Date
Guardian/Legal Representative Signature - by signing this form, I authorize you to release confidential health information about me and by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/facility/entity listed below:
Date
-
Month
-
Day
Year
Today's Date
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